Coronary Artery Disease

UHCW Cardiology TeachingDr Chris McAloon

65 year old man Playing golf Sudden onset chest pain Crushing, central, severe Vomiting No previous chest pain HTN, Ex-Smoker Otherwise well GTN helped – not resolved

Case One

History – what information do you need to elicit?

Pain ◦ Character / Radiation / GTN spray effect◦ Was this pain like your previous Angina/ MI

pain? Autonomic features Risk factors

◦ Smoker / Hypertension / Diabetes Hyperlipidaemia / Family history

◦ Previous MI / CABG / PCI / CVA Differentials

Central Crushing Chest Pain Exertional chest pain Occurs at rest Radiation

◦ Neck, arms (classically left) Levine’s Sign

◦ Clenched fist over chest Breathless Autonomic features

Cardiac Sounding Chest Pain

Isn’t Chest Pain always ACS?

ECS ACS NTE Guidelines 2011

Examination Nicotine Stains GTN spray Xanthelasma Scar’s

◦ Chest◦ Legs

Evidence DM BP/ Pulse/ Failure

Examination

65 year old ◦ Ankles/shins for SVG

scar◦ Radial for graft scar

CABG

35 year old◦ Metallic Click◦ Look left lateral ◦ Cyanosis etc

Valve/ Congenital surgery

Acute Coronary Syndrome

ECS ACS Guidelines 2011

ESC Definition ACS Pain

ECS ACS Guidelines 2011

Grech E D , Ramsdale D R BMJ 2003;326:1259-1261

©2003 by British Medical Journal Publishing Group

Pathophysiology ACS

Grech E D , Ramsdale D R BMJ 2003;326:1259-1261

©2003 by British Medical Journal Publishing Group

Plaque and Thrombin Formation

Ischaemic Heart Disease

Grech E D , Ramsdale D R BMJ 2003;326:1379-1381©2003 by British Medical Journal Publishing Group

Ruptured Atheromatous Plaque and Occlusive Thrombus

STEMI

ECG: ST elevation

ECG Changes Site of Infarction

Vessel Occluded

V1-V3 Anteroseptal LAD

V4, V5, AVL, I Anterior Lateral LAD, diagonal

Widespread 1, AVL, V1-V6

Large Anterior Prox LAD (could be LMS- Pump probs

II, III, AVF Inferior RCA (or Cx)- Bradyarrhythmia

↓ ST V1-V2↑ ST in post leads

Posterior RCA (or Cx)

NB remember Cx occlusion can be silent on the ECG

ANTERIOR STEMI ST elevation V1-V6, reciprocal changes in II, III, AVF

Infero-posterior STEMI ST elevation in II, III and AF, R wave and ST depression in V1-2

Size of the Problem: England and Wales 2009-10

STEMI 31,412 in 2009-10 Frequency falling

NSTEMI Estimated 100, 000 in 2009-10 Recorded frequency rising 50% not managed on ACU/ CCU

BCS Recommendations Acute Coronary Care Oct 2011

30 Day Mortality

BCS Recommendations Acute Coronary Care Oct 2011

STEMI Initial Diagnosis

ECS ACS STE Guidelines 2011

Management of STEMI

(GTN)↓

High Flow Oxygen (15L)↓

300mg Aspirin/ 600mg Clopidogrel↓

Analgesia: Morphine + Metoclopramide↓

Reperfusion: PCI / Fibrinolysis

THINK REPERFUSION STRATEGY:

■ Primary PCI if available (CALL THE CATH LAB) ■ Thrombolysis if not, then refer to PCI centre

STEMI Management

ECS Revasculration Guidelines 2011

Successful Thrombolysis ST segment

resolution 50% at 90 minutes

Direct paramedic transfer to PPCI centre or timely inter-hospital transfer

PPCI with first medical contact-to-balloon time <120 minutes

Monitoring on CCU (including for repatriated patients)

Early initiation of secondary prevention and cardiac rehabilitation

Standards STEMI Management

ECS Revasculration Guidelines 2011

The Changing Face STEMI Mx

BCS Recommendations Acute Coronary Care Oct 2011

95% England covered by PPCI networks Thrombolysis remains in place in remote

centres◦ Geography impacts time to PPCI centre

30% Thrombolysis fail to reperfuse and need immediate rescue PCI

The Changing Face STEMI Mx

ECS ACS STE Guidelines 2011

Disruption of occlusion using a balloon Stent deployed to maintain anterograde

blood flowTypes Primary PCI – PCI within 2 hours Rescue PCI – PCI after failed thrombolysis Facilitated PCI – PCI bridged with lytic

therapy◦ Time delayed PPCI

What is Percutaneous Coronary Intervention (PCI)?

Grech E D , Ramsdale D R BMJ 2003;326:1259-1261

©2003 by British Medical Journal Publishing Group

Distal Embolisation of a Platelet-Rich Thrombus causing Occlusion

of Intramyocardial Arteriole

NSTEMI

48 year old lady Shopping Central dull Pain on walking Not relieved GTN spray Gets on exertion normally Recently distant decreasing to onset pain Pain last night in bed

Case Two

Grech E D , Ramsdale D R BMJ 2003;326:1259-1261

©2003 by British Medical Journal Publishing Group

Worrying ECG?

What do you do as the SHO clerking patient in

A+E?

Defining Angina Pectoris Stable Angina

◦ pattern of frequency, intensity, ease of provocation, or duration does not change over several weeks

Accelerating Angina◦  change in the pattern of stable angina◦ greater ease of provocation, more prolonged

episodes, and episodes of greater severity or more frequent use of sublingual GTN

Unstable Angina◦  pattern of chest pain changes abruptly

Three Presentations UA Angina at rest—Also prolonged, usually >

20 minutes Angina of new onset—At least CCS class III

in severity Angina increasing—Previously diagnosed

angina that has become more frequent, longer in duration, or lower in threshold (change in severity by > 1 CCS class to at least CCS class III)

Class I – Pain strenuous exertion Class II – Slight limitation ordinary exertion Class III – Marked limitation physical

exertion Class IV – Pain on any exertion

CCS = Canadian Cardiology Society

Angina Pectoris CCS Classification

TIMI Risk Score ≥3 risk factors for coronary artery disease ≥50% coronary stenosis on angiography ST segment change >0.5 mm ≥2 anginal episodes in 24 hours before

presentation Elevated serum concentration of cardiac

markers Use of aspirin in 7 days before presentation

Grech E D , Ramsdale D R BMJ 2003;326:1259-1261

©2003 by British Medical Journal Publishing Group

High TIMI score and Mortality

Bleeding Risk

ECS ACS Guidelines 2011

NSTEMI Outcome Based Location

BCS Recommendations Acute Coronary Care Oct 2011

Simplified management pathway for patients with unstable angina or non-ST segment elevation myocardial infarction.

Grech E D , Ramsdale D R BMJ 2003;326:1259-1261

©2003 by British Medical Journal Publishing Group

Acute Management of NSTEMI-ACS Aspirin 300mg Clopidogrel 300mg (600mg if going to

the lab) LMWH Bisoprolol / Atorvastatin 80mg ON/

ACE/ARB (can be next day) GTN Spray/ Infusion

HIGH RISK patients: GPIIbIIIa Cath Lab within 48-96hrs

High risk (GRACE >140) within 24 hours◦ At Stafford discuss with Stoke

Intermediate risk (GRACE < 140) and high risk criterion within 72 hours

Low risk with recurrent symptoms◦ Stress Test

Timing Early Invasive Strategy

ECS ACS Guidelines 2011

Anti-thrombotic Therapy

Thienopyridine related to Clopidogrel Active metabolite irreversible inhibitor of

ADP receptor Effective when Clopidogrel Resistance More rapid/ greater/ more consistent

platelet inhibition No drug interactions Licensed used STEMI going PPCI

Prasugrel

Wiviott SD et al. N Engl J Med 2007;357:2001-2015

Prasugrel vs Clopidogrel

Wiviott SD et al. N Engl J Med 2007;357:2001-2015

Prasugrel vs Clopidogrel

Ticagrelor Cyclopentyl-triazolo-pyrimidine Reversible inhibitor of ADP receptor Rapid/ Predictable action CYP450 interaction NICE approval October 2011 ACS

Wallentin L et al. N Engl J Med 2009;361:1045-1057

Ticagrelor vs Clopidogrel

Wallentin L et al. N Engl J Med 2009;361:1045-1057

Ticagrelor vs Clopidogrel

Prescribing in CKD

ECS ACS Guidelines 2011

Secondary Prevention for IHDImmediately Aspirin ± PPI (Bleeding risk) Clopidogrel (12 months) B Blocker ACEi- if intolerant give ARB Atorvastatin 80mg GTN Spray PRN

◦ 15 minute rule

Lifestyle Diet Physical Activity Stop Smoking Cardiac Rehab

Definitions ACS Incidence and Prevalence Pathophysiology Differential Diagnoses STEMI Intervention – current evidence NSTEMI intervention – current evidence Antithrombotic therapy use New anti-thrombotics

Summary